Endometrial pathology in the postmenopausal woman – an evidence based approach to management

Abstract

This article outlines how to identify the symptoms and signs associated with endometrial pathology and how these correlate with the final diagnosis. The evidence for and against intervention in asymptomatic women with a coincidental finding of endometrial pathology is discussed. This article looks at how best to investigate symptomatic women on hormone replacement therapy (HRT) and selective estrogen receptor modulators (SERMs). Screening for endometrial pathology is discussed. Learning objectivesTo be able to identify risk factors associated with postmenopausal endometrial pathology, as well as symptoms and signs.To learn about the models of care for different endometrial pathology. To understand the contentious issues and the risk-benefit profile of different strategies for the management of asymptomatic women. Ethical issuesDoes an incidental finding of a thick endometrium in asymptomatic postmenopausal women warrant further investigation? Should asymptomatic women receiving HRT or SERMs be routinely screened and investigated?

Clinical and Sonographic Evaluation of Postmenopausal Bleeding (PMB) Followed by Diagnostic and/or Therapeutic Hysteroscopy and Guided Biopsy in Jordanian Hospitals

“…Endometrial biopsy is recommended for symptomatic women with the symptom of thickened persistentendometrium and endometrium bleeding. An incidental result of the endometrial pathology in asymptomatic postmenopausal women poses a clinical management dilemma [7].…”

“…It may also permit a direct view of the endometrium and biopsies, which can be considered an advantage that enhances diagnostic accuracy, specifically in regard tofocal lesions [8]. There is limited value of routine screening with endometrial biopsy in asymptomatic women on tamoxifen [7]. All the spotted and abnormal bleeding must be investigated, but pipelle endometrial biopsyrarely provides useful diagnostic knowledge among women treated with tamoxifen.…”

“…Therefore, it has been suggested that symptomatic women who have thickened endometrium must be investigated with a targeted biopsy and hysteroscopy. The thickened endometriummainly occurs due to the tamoxifen-induced subepithelial stromal hypertrophy [7].…”

The significance of “Atrophic Endometrium” in Women with Postmenopausal Bleeding.

“…3) The notion that AE is the cause of PMB has allowed some health care providers to "treat" the AE with estrogens. The concept of treating AE is present in textbooks and guidelines for physicians and patients (45)(46)(47)(48)(49) . We could not find any study that examined the safety or outcome of this management.…”

Can vaginal ultrasound replace diagnostic curettage in the detection of endometrial pathology in post-menopausal bleeding?

“…The polyp may be broad-based and sessile or pedunculated, and the stalk of the polyp may be seen if sufficient fluid is present in the endometrial cavity. 12 The finding of a single feeding vessel or single vascular stalk to a suspected polyp has been demonstrated to confirm the presence of a polyp with a specificity and negative predictive value of 95% and 94% respectively. 13 Endometrial carcinoma may occur in the form of a polyp, within endometrial hyperplasia, or as a heterogeneous endometrial mass with a widened irregular cavity, other ultrasound features of endometrial carcinoma include heterogeneity and irregular endometrial thickening.…”